Southern Ohio Medical Center

All Charges

Charge

Type

Setting

Price

REPAIR HERNIA FEM INCAR

Professional

Both

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	76102018
Hospital Revenue Code	761
Min. Negotiated Rate	$364.36
Max. Negotiated Rate	$1,080.00
Rate for Payer: Aetna Commercial	$897.71
Rate for Payer: Ambetter Exchange	$605.18
Rate for Payer: Anthem Medicaid	$364.36
Rate for Payer: Buckeye Individual/Medicaid	$605.18
Rate for Payer: Buckeye Medicare Advantage	$605.18
Rate for Payer: CareSource Just4Me Medicare	$726.22
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$835.96
Rate for Payer: Healthspan PPO	$757.05
Rate for Payer: Humana Medicaid	$364.36
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$798.04
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$605.18
Rate for Payer: Molina Healthcare Benefit Exchange	$605.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$371.65
Rate for Payer: Molina Healthcare Passport	$364.36
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$786.73
Rate for Payer: UHCCP Medicaid	$630.00
Rate for Payer: Wellcare CHIP/Medicaid	$368.00
Rate for Payer: Wellcare Medicare Advantage	$605.18

REPAIR HERNIA FEM INCAR

Facility

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	76102018
Hospital Revenue Code	761
Min. Negotiated Rate	$540.00
Max. Negotiated Rate	$1,728.00
Rate for Payer: Aetna Commercial	$1,386.00
Rate for Payer: Anthem POS/PPO/Traditional	$1,404.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$1,494.00
Rate for Payer: First Health Commercial	$1,710.00
Rate for Payer: Humana Commercial	$1,530.00
Rate for Payer: Medical Mutual Of Ohio HMO	$1,476.00
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$1,328.40
Rate for Payer: Molina Healthcare Benefit Exchange	$540.00
Rate for Payer: Ohio Health Choice Commercial	$1,584.00
Rate for Payer: Ohio Health Group HMO	$1,350.00
Rate for Payer: Ohio Health Group PPO Differential	$1,440.00
Rate for Payer: Ohio Health Group PPO No Differential	$1,566.00
Rate for Payer: Ohio Health Group PPO SOMC Employees	$1,242.00
Rate for Payer: PHCS Commercial	$1,728.00
Rate for Payer: United Healthcare All Payer	$1,584.00

REPAIR HERNIA FEM INCAR(P

Professional

Both

$1,800.00

Service Code	HCPCS 49553
Hospital Charge Code	761P2018
Hospital Revenue Code	761
Min. Negotiated Rate	$364.36
Max. Negotiated Rate	$1,080.00
Rate for Payer: Aetna Commercial	$897.71
Rate for Payer: Ambetter Exchange	$605.18
Rate for Payer: Anthem Medicaid	$364.36
Rate for Payer: Buckeye Individual/Medicaid	$605.18
Rate for Payer: Buckeye Medicare Advantage	$605.18
Rate for Payer: CareSource Just4Me Medicare	$726.22
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cash Price	$900.00
Rate for Payer: Cigna Commercial	$835.96
Rate for Payer: Healthspan PPO	$757.05
Rate for Payer: Humana Medicaid	$364.36
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$798.04
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$605.18
Rate for Payer: Molina Healthcare Benefit Exchange	$605.18
Rate for Payer: Molina Healthcare CHIP/Medicaid	$371.65
Rate for Payer: Molina Healthcare Passport	$364.36
Rate for Payer: Multiplan PHCS	$1,080.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$786.73
Rate for Payer: UHCCP Medicaid	$630.00
Rate for Payer: Wellcare CHIP/Medicaid	$368.00
Rate for Payer: Wellcare Medicare Advantage	$605.18

REPAIR HUMERUS WITH GRAFT

Professional

Both

$1,105.00

Service Code	HCPCS 24435
Hospital Charge Code	76102740
Hospital Revenue Code	360
Min. Negotiated Rate	$386.75
Max. Negotiated Rate	$1,694.30
Rate for Payer: Aetna Commercial	$1,566.08
Rate for Payer: Ambetter Exchange	$1,027.09
Rate for Payer: Anthem Medicaid	$845.40
Rate for Payer: Buckeye Individual/Medicaid	$1,027.09
Rate for Payer: Buckeye Medicare Advantage	$1,027.09
Rate for Payer: CareSource Just4Me Medicare	$1,232.51
Rate for Payer: Cash Price	$552.50
Rate for Payer: Cash Price	$552.50
Rate for Payer: Cigna Commercial	$1,694.30
Rate for Payer: Healthspan PPO	$1,418.54
Rate for Payer: Humana Medicaid	$845.40
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$1,337.23
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$1,027.09
Rate for Payer: Molina Healthcare Benefit Exchange	$1,027.09
Rate for Payer: Molina Healthcare CHIP/Medicaid	$862.31
Rate for Payer: Molina Healthcare Passport	$845.40
Rate for Payer: Multiplan PHCS	$663.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$1,335.22
Rate for Payer: UHCCP Medicaid	$386.75
Rate for Payer: Wellcare CHIP/Medicaid	$853.85
Rate for Payer: Wellcare Medicare Advantage	$1,027.09

REPAIR ING HERNIA SLIDING

Facility

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$268.24
Max. Negotiated Rate	$4,565.09
Rate for Payer: Aetna Commercial	$600.60
Rate for Payer: Anthem Medicaid	$268.24
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Anthem POS/PPO/Traditional	$608.40
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$647.40
Rate for Payer: First Health Commercial	$741.00
Rate for Payer: Humana Commercial	$663.00
Rate for Payer: Humana KY Medicaid	$268.24
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Kentucky WC Medicaid	$270.97
Rate for Payer: Medical Mutual Of Ohio HMO	$639.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$575.64
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94
Rate for Payer: Molina Healthcare Medicaid	$273.62
Rate for Payer: Ohio Health Choice Commercial	$686.40
Rate for Payer: Ohio Health Group HMO	$585.00
Rate for Payer: Ohio Health Group PPO Differential	$624.00
Rate for Payer: Ohio Health Group PPO No Differential	$678.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$538.20
Rate for Payer: PHCS Commercial	$748.80
Rate for Payer: United Healthcare All Payer	$686.40

REPAIR ING HERNIA SLIDING

Professional

Both

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$816.13
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Ambetter Exchange	$549.94
Rate for Payer: Anthem Medicaid	$381.57
Rate for Payer: Buckeye Individual/Medicaid	$549.94
Rate for Payer: Buckeye Medicare Advantage	$549.94
Rate for Payer: CareSource Just4Me Medicare	$659.93
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$759.55
Rate for Payer: Healthspan PPO	$688.26
Rate for Payer: Humana Medicaid	$381.57
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$723.14
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$549.94
Rate for Payer: Molina Healthcare Benefit Exchange	$549.94
Rate for Payer: Molina Healthcare CHIP/Medicaid	$389.20
Rate for Payer: Molina Healthcare Passport	$381.57
Rate for Payer: Multiplan PHCS	$468.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$714.92
Rate for Payer: UHCCP Medicaid	$273.00
Rate for Payer: Wellcare CHIP/Medicaid	$385.39
Rate for Payer: Wellcare Medicare Advantage	$549.94

REPAIR ING HERNIA SLIDING

Facility

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	76102016
Hospital Revenue Code	761
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna Commercial	$600.60
Rate for Payer: Anthem POS/PPO/Traditional	$608.40
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$647.40
Rate for Payer: First Health Commercial	$741.00
Rate for Payer: Humana Commercial	$663.00
Rate for Payer: Medical Mutual Of Ohio HMO	$639.60
Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional	$575.64
Rate for Payer: Molina Healthcare Benefit Exchange	$234.00
Rate for Payer: Ohio Health Choice Commercial	$686.40
Rate for Payer: Ohio Health Group HMO	$585.00
Rate for Payer: Ohio Health Group PPO Differential	$624.00
Rate for Payer: Ohio Health Group PPO No Differential	$678.60
Rate for Payer: Ohio Health Group PPO SOMC Employees	$538.20
Rate for Payer: PHCS Commercial	$748.80
Rate for Payer: United Healthcare All Payer	$686.40

REPAIR ING HERNIA SLIDING(P

Professional

Both

$780.00

Service Code	HCPCS 49525
Hospital Charge Code	761P2016
Hospital Revenue Code	761
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$816.13
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Ambetter Exchange	$549.94
Rate for Payer: Anthem Medicaid	$381.57
Rate for Payer: Buckeye Individual/Medicaid	$549.94
Rate for Payer: Buckeye Medicare Advantage	$549.94
Rate for Payer: CareSource Just4Me Medicare	$659.93
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cash Price	$390.00
Rate for Payer: Cigna Commercial	$759.55
Rate for Payer: Healthspan PPO	$688.26
Rate for Payer: Humana Medicaid	$381.57
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$723.14
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$549.94
Rate for Payer: Molina Healthcare Benefit Exchange	$549.94
Rate for Payer: Molina Healthcare CHIP/Medicaid	$389.20
Rate for Payer: Molina Healthcare Passport	$381.57
Rate for Payer: Multiplan PHCS	$468.00
Rate for Payer: Ohio Health Choice Preferred Health Choice	$714.92
Rate for Payer: UHCCP Medicaid	$273.00
Rate for Payer: Wellcare CHIP/Medicaid	$385.39
Rate for Payer: Wellcare Medicare Advantage	$549.94

REPAIR INGUINAL HERNIA, SLIDING, ANY AGE

Facility

$4,565.09

Service Code	CPT 49525
Hospital Revenue Code	360
Min. Negotiated Rate	$3,260.78
Max. Negotiated Rate	$4,565.09
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94

REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR STRANGULATED

Facility

$4,565.09

Service Code	CPT 49553
Hospital Revenue Code	360
Min. Negotiated Rate	$3,260.78
Max. Negotiated Rate	$4,565.09
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94

REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE

Facility

$4,565.09

Service Code	CPT 49550
Hospital Revenue Code	360
Min. Negotiated Rate	$3,260.78
Max. Negotiated Rate	$4,565.09
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR STRANGULATED

Facility

$4,565.09

Service Code	CPT 49507
Hospital Revenue Code	360
Min. Negotiated Rate	$3,260.78
Max. Negotiated Rate	$4,565.09
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94

REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE

Facility

$4,565.09

Service Code	CPT 49505
Hospital Revenue Code	360
Min. Negotiated Rate	$3,260.78
Max. Negotiated Rate	$4,565.09
Rate for Payer: Anthem Medicare Advantage/PPO	$3,260.78
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$4,565.09
Rate for Payer: CareSource Just4Me Medicare	$4,402.05
Rate for Payer: Humana Medicare Advantage	$3,260.78
Rate for Payer: Molina Healthcare Benefit Exchange	$3,912.94

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS

Facility

$516.82

Service Code	CPT 12051
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

Facility

$516.82

Service Code	CPT 12053
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS

Facility

$516.82

Service Code	CPT 12041
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM

Facility

$516.82

Service Code	CPT 12042
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM

Facility

$791.84

Service Code	CPT 12044
Hospital Revenue Code	360
Min. Negotiated Rate	$565.60
Max. Negotiated Rate	$791.84
Rate for Payer: Anthem Medicare Advantage/PPO	$565.60
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$791.84
Rate for Payer: CareSource Just4Me Medicare	$763.56
Rate for Payer: Humana Medicare Advantage	$565.60
Rate for Payer: Molina Healthcare Benefit Exchange	$678.72

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM

Facility

$516.82

Service Code	CPT 12035
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM

Facility

$791.84

Service Code	CPT 12036
Hospital Revenue Code	360
Min. Negotiated Rate	$565.60
Max. Negotiated Rate	$791.84
Rate for Payer: Anthem Medicare Advantage/PPO	$565.60
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$791.84
Rate for Payer: CareSource Just4Me Medicare	$763.56
Rate for Payer: Humana Medicare Advantage	$565.60
Rate for Payer: Molina Healthcare Benefit Exchange	$678.72

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS

Facility

$516.82

Service Code	CPT 12031
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

Facility

$516.82

Service Code	CPT 12032
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM

Facility

$516.82

Service Code	CPT 12034
Hospital Revenue Code	360
Min. Negotiated Rate	$369.16
Max. Negotiated Rate	$516.82
Rate for Payer: Anthem Medicare Advantage/PPO	$369.16
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$516.82
Rate for Payer: CareSource Just4Me Medicare	$498.37
Rate for Payer: Humana Medicare Advantage	$369.16
Rate for Payer: Molina Healthcare Benefit Exchange	$442.99

REPAIR, INTERMEDIATE, WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM

Facility

$2,366.24

Service Code	CPT 12037
Hospital Revenue Code	360
Min. Negotiated Rate	$1,690.17
Max. Negotiated Rate	$2,366.24
Rate for Payer: Anthem Medicare Advantage/PPO	$1,690.17
Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage	$2,366.24
Rate for Payer: CareSource Just4Me Medicare	$2,281.73
Rate for Payer: Humana Medicare Advantage	$1,690.17
Rate for Payer: Molina Healthcare Benefit Exchange	$2,028.20

REPAIR INTERM. NECK - HAND -

Professional

Both

$881.00

Service Code	HCPCS 12041
Hospital Charge Code	76100138
Hospital Revenue Code	761
Min. Negotiated Rate	$72.85
Max. Negotiated Rate	$528.60
Rate for Payer: Aetna Commercial	$239.82
Rate for Payer: Ambetter Exchange	$136.77
Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional	$72.85
Rate for Payer: Anthem Medicaid	$92.55
Rate for Payer: Buckeye Individual/Medicaid	$136.77
Rate for Payer: Buckeye Medicare Advantage	$136.77
Rate for Payer: CareSource Just4Me Medicare	$164.12
Rate for Payer: Cash Price	$440.50
Rate for Payer: Cash Price	$440.50
Rate for Payer: Cigna Commercial	$295.96
Rate for Payer: Healthspan PPO	$272.20
Rate for Payer: Humana Medicaid	$92.55
Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation	$213.17
Rate for Payer: Medical Mutual Of Ohio Medicare Advantage	$136.77
Rate for Payer: Molina Healthcare Benefit Exchange	$136.77
Rate for Payer: Molina Healthcare CHIP/Medicaid	$94.40
Rate for Payer: Molina Healthcare Passport	$92.55
Rate for Payer: Multiplan PHCS	$528.60
Rate for Payer: Ohio Health Choice Preferred Health Choice	$177.80
Rate for Payer: UHCCP Medicaid	$76.49
Rate for Payer: Wellcare CHIP/Medicaid	$93.48
Rate for Payer: Wellcare Medicare Advantage	$136.77

Know your out-of-pocket cost for care.

All Charges